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Rituals evolve around clinical practices in the belief that they prevent post-operative wound infections. Many procedures are based upon custom and practice, including removing a patient’s personal clothing and jewellery, and using hats to cover their hair.

Recommendations include:

• removing all the patient’s clothing may be unnecessary
• don’t remove a patient’s jewellery or rings, unless they are on the area of the body being operated on, or unless they may obstruct the giving of an anaesthetic.

Pre-operative shaving has long been practised in the belief that hair removal reduces the incidence of wound infection. This was traditionally undertaken the night before the operation, but the methods used caused microscopic infected lacerations by the time of the operation. In 1973 using depilatory creams was demonstrated to reduce infection rates, and in 1983 using hair clippers produced fewer infections than shaving.

Recommendations for pre-operative shaving are:

• avoid shaving
• use depilatory creams or clippers
• only shave if other options are not possible
• don’t use shaving brushes
• only shave the area of incision
• if using depilatory cream it can be done the day before operation
• if having to shave this should be done in the anaesthetic room immediately pre-operatively using clippers rather than a razor.

It was traditional to ask patients to take a bath or shower before their operation but the studies have been inconclusive as to whether this reduces the risk of wound infections. Repeated showers using chlorhexidine appear to reduce the number of bacteria on the skin but this doesn’t seem to result in a significant reduction in the incidence of postoperative wound infections. Two approaches seem to be taken: UK guidance doesn’t recommend preoperative bathing as there is no evidence to support this practice, whereas USA guidance suggests that whilst there is no evidence to support the practice, it may help.

Hand cleansing by staff is an important part of clinical practice especially before performing surgical procedures. An appropriate technique and choice of lotion can be found in the hand hygiene section.

The two most popular skin preparations for the patient are 1% iodine in 70% alcohol and 0.5% chlorhexidine in 70% alcohol.

Recommendations include:

• alcohol solutions are preferable to aqueous solutions for skin preparation, but allow the alcohol to dry after its application before using electrocautery
• solutions should be available in single-use sachets and not multi-use bottles as they can become contaminated on repeated opening
• if multi-use bottles are used they should be used by the ‘use by date’ and not refilled.

To reduce the risk of postoperative wound infections from the environment or exogenous sources, personal protective equipment (PPE) such as hats, gowns, masks and surgical drapes are used. Also included as a method of prevention is the use of sterile surgical instruments.

There is little evidence to support the routine wearing of face masks by all healthcare workers in the operating room. They were introduced because it was thought that bacteria from the nose and throat of surgical staff contributed to post-operative wound infections. However the organisms that are dispersed when talking are few and can be removed by the different ventilation systems in use. The exception to this rule is prosthetic orthopaedic operations which are more susceptible to such organisms.

Nowadays, masks are used to protect the wearer from blood and body fluid splashes from patients during surgery to the operating team.

Recommendations include:

• wearing double gloves for surgical procedures to protect against viral transmission by the operator
• face masks to be worn to protect the wearer from body fluid splashes
• face masks to be worn by the ‘scrub’ team for prosthetic implant operations
• masks should be changed after each operation or if they become contaminated or saturated
• it is not necessary for the non-scrubbed operating team to wear disposable headgear, however hair should be kept clean and long hair tied back
• hats must be worn in laminar flow theatre during prosthetic implant operations
• theatre gowns and drapes should be made of waterproof, disposable material.

The function of ventilation systems in an operating room environment is to prevent airborne microbial contaminants from entering surgical wounds. The main source of airborne contamination is microscopic skin fragments given off by staff in theatre – a proportion of which will be contaminated with microbes on that individual’s skin. Dispersion is increased with movement and the number of people present.

Airborne microbes can enter surgical wounds by either falling directly into wounds or they can land on exposed instruments and possibly the surgeons’ hands, and then be transferred into the wound. The patient is not usually a significant source of airborne contamination as their movement is usually minimal. However, with the use of power tools these can create aerosols from the tissues and any microbes in them.

Surgical operations and other invasive procedures are performed in a number of different settings that have various levels of bacteriological control of the ventilation system. These include:

• conventionally-ventilated operating suites
• ultraclean-ventilated (UCV) operating theatres
• unventilated theatres
• treatment rooms.

Health Technical Memorandum (HTM) 2025 provides guidance for conventional and ultra-clean ventilation theatre and states the limits on microbiological (bacterial and fungal) content of air in empty and working theatres.

Commissioning must occur before an operating theatre is first used and after any substantial modifications that may affect airflow patterns in operating theatres as part of a re-commissioning process. It is important that the infection control team is involved at all stages, from pre-design through to opening, and that sufficient time for commissioning is built in to the schedule, including an allowance of time for microbiological assessments.